Avon Lodge and Avon Lodge Annex

Updated 7 October 2023

The inspection

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 (the Act) as part of our regulatory functions. We checked whether the provider was meeting the legal requirements and regulations associated with the Act. We looked at the overall quality of the service and provided a rating for the service under the Health and Social Care Act 2008.

Inspection team

The inspection was completed by 2 inspectors, a pharmacist specialist and an Expert by Experience. An Expert by Experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Service and service type

Avon Lodge and Avon Lodge Annex is a ‘care home’. People in care homes receive accommodation and nursing and/or personal care as a single package under one contractual agreement dependent on their registration with us. Avon Lodge and Avon Lodge Annex is a care home without nursing care. CQC regulates both the premises and the care provided, and both were looked at during this inspection.

This service is also registered to provide domiciliary care to people living in their own houses and flats as well as personal care to people living in ‘supported living’ settings, so that they can live as independently as possible. In supported living, people’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for supported living.

Registered Manager

This provider is required to have a registered manager to oversee the delivery of regulated activities at this location. A registered manager is a person who has registered with the CQC to manage the service. Registered managers and providers are legally responsible for how the service is run, for the quality and safety of the care provided and compliance with regulations.

At the time of our inspection there was a new manager in post who was in the process of applying to become the registered manager.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received about the service since the last inspection. We used the information the provider sent us in the provider information return (PIR). This is information providers are required to send us annually with key information about their service, what they do well, and improvements they plan to make. We sought feedback from Healthwatch, the local authority and professionals who worked with the service. Healthwatch is an independent consumer champion that gathers and represents the views of the public about health and social care services in England. We used all this information to plan our inspection.

During the inspection

We spoke with 3 people and 5 of their relatives about their experience of using the service. We received feedback from 3 health and social care professionals who worked with the service. We spoke with 8 members of staff including the manager and support workers.

We reviewed a range of records. This included 6 people's care records and 5 people’s medicine administration records. We looked at 4 staff files in relation to recruitment, training and supervision. A variety of other records relating to the management of the service, including audits and policies and procedures were also reviewed.

We used technology including electronic file sharing to enable us to review additional documentation following our site visits.

Updated 7 October 2023

About the service

Avon Lodge and Avon Lodge Annex is a residential care home providing accommodation and personal care for up to 12 younger adults and older people who may be living with mental health needs, a learning disability or autism. Accommodation was provided over 3 floors of an adapted house in a residential area.

The service is also registered to provide domiciliary care to people living in their own homes or ‘supported living’ settings, so that they can live as independently as possible. With supported living people’s care and housing are provided under separate contractual agreements. The Care Quality Commission (CQC) does not regulate premises used for supported living.

At the time of our inspection there were 7 people receiving residential care. The service was not providing a domiciliary care service and whilst people were living in supported living accommodation next door to the residential care home, they were not receiving support with personal care at the time of our inspection. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating.

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

We expect health and social care providers to guarantee people with a learning disability and autistic people respect, equality, dignity, choices and independence and good access to local communities that most people take for granted. ‘Right support, right care, right culture’ is the guidance CQC follows to make assessments and judgements about services supporting people with a learning disability and autistic people and providers must have regard to it.

Right Support:

People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests; the policies and systems in the service did not support this practice.

People's legal rights were not protected. Records were not available to show staff had followed an appropriate process to decide someone lacked mental capacity or to make decisions on their behalf.

People did not have free access to any safe outside space.

Right Care:

People were at increased risk of receiving ineffective or unsafe care. Their care plans and risk assessments were not always detailed and person-centred. They did not always show people’s needs had been thoroughly assessed or that robust plans were in place to guide staff on how best to meet their needs whilst minimising risks.

People were not protected from the risk of avoidable harm. A robust system was not in place to ensure accidents and incidents were appropriately recorded and responded to.

We could not be certain staff deployed had been safely recruited or that they were safe to continue working at the service. The provider had not ensured agency staff had received a suitable induction and had the information they needed to work safely at the service.

Areas of the service were not clean. There were issues with the maintenance and upkeep of the environment and management of risks. Some areas of the service were not warm and welcoming and felt impersonal.

Medicines were mostly managed safely. However, there were some issues with records and guidance for topical medicines and medicines taken ‘when required’, which increased the risk people would not receive their medicines consistently.

Right Culture:

There remained widespread issues with how the service was managed. Risks and issues had not been adequately addressed to improve the quality and safety of the service. Audits had not been used effectively to identify and drive improvements since the last inspection.

Whilst there was generally positive feedback about the new manager and the changes they had made, overall leaders and the culture they created did not assure the delivery of high-quality person-centred care.

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 15 May 2023) and there were multiple breaches of regulation. We issued a Warning Notice following the last inspection in relation to Regulation 17(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At this inspection, we found the provider remained in breach of regulations. This service has been rated requires improvement or inadequate for the last 2 consecutive inspections.

Why we inspected

We undertook this focused inspection to follow up on action we told the provider to take at the last inspection and to check whether the Warning Notice we served in relation to Regulation 17(1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 had been met.

This report only covers our findings in relation to the Key Questions Safe, Effective and Well-led which contain those requirements. For those key questions not inspected, we used the ratings awarded at previous inspections to calculate the overall rating.

The overall rating for the service has changed from requires improvement to inadequate based on the findings of this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Avon Lodge and Avon Lodge Annex on our website at www.cqc.org.uk.

Enforcement

We have identified breaches in relation to the safety of the service, the environment and the provider’s oversight and governance arrangements at this inspection.

Full information about CQC’s regulatory response to the more serious concerns found during inspections is added to reports after any representations and appeals have been concluded.

Follow up

We will request an action plan from the provider to understand what they will do to improve the standards of quality and safety. We will work alongside the provider and local authority to monitor progress. We will continue to monitor information we receive about the service, which will help inform when we next inspect.

Special Measures

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘special measures’. This means we will keep the service under review and, if we do not propose to cancel the provider’s registration, we will re-inspect within 6 months to check for significant improvements.

If the provider has not made enough improvement within this timeframe and there is still a rating of inadequate for any key question or overall rating, we will take action in line with our enforcement procedures. This will mean we will begin the process of preventing the provider from operating this service. This will usually lead to cancellation of their registration or to varying the conditions the registration.

For adult social care services, the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it, and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.