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Inspection Summary

Overall summary & rating


Updated 14 September 2018

This inspection took place on the 19 and 20 July 2018 and was unannounced.

At our last inspection on 19 September 2016 we found improvements were needed to ensure the providers governance arrangements identified shortfalls and reflected the action taken to address these. This included, ensuring applications to deprive people of their liberty were made to the local authority for authorisation and ensuring people received their medicines as prescribed by their GP.

At this inspection we found the required improvements had been made, however we found the systems for monitoring risks to people needed improving. For example, where unexplained bruising or skin tears had occurred, no incident report was completed, just a body map. The charts did not show what action had been taken to investigate what had happened, or if the appropriate authorities were informed if after investigation they remained ‘unexplained’. However, the deputy manager could tell us, in detail about each incident and what follow up action had been taken to ensure people’s health, safety and welfare. The registered manager took immediate action during the inspection to revise the form, which incorporated a body map and process for reporting incidents.

Aveley Lodge 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 service is a 25 bedded residential home providing care and support to older people, some of whom may be living with dementia. The premises was well maintained, bright, welcoming and clean. On the day of our inspection there were 24 people living in the home.

A registered manager was 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.’

People told us Aveley Lodge was a safe and secure place to live. People had been informed of what they needed to do to keep safe, including fire safety and how to raise concerns. Staff knew the process to follow and whom to inform both within the organisation and to outside agencies if they witnessed or had an allegation of abuse reported to them.

People were provided with the support they needed to promote their independence and freedom, yet minimise the risks. People received their medicines when they needed them.

There was enough staff available to meet people's needs. Staffing numbers had been calculated based on the needs of the people using the service. Thorough recruitment and selection processes were in place which ensured staff recruited had the right skills and experience. The provider was committed to providing a continuous cycle of training that ensured staff had the right skills and knowledge to meet people's needs. A buddy system was used to ensure new staff were supported. Staff spoke consistently about the service being a good place to work. They felt supported, received regular supervision and had access to plenty of training opportunities.

People were supported to eat and drink and maintain a balanced diet. Staff were aware of people's dietary needs and the support they needed to eat their meal. Mealtimes were a positive, sociable experience for people with a good ratio of staff present to ensure they received the support they needed to eat their meal.

The provider had worked hard to create positive and lasting links with community health services. People were supported to maintain their health. Their records confirmed they had access to a range of healthcare services including the GP, optician, specialist nurses and dietician.

People were supported to express their views and make decisions about their care. Peo

Inspection areas



Updated 14 September 2018

The service was safe.

Systems were in place to identify potential abuse and reduce risks to people using the service.

Staff demonstrated a good awareness of safeguarding procedures and how to recognise and report signs of neglect or abuse. People and their relatives told us this was a very good service and that it was a safe place to live.

There were enough staff to meet people's needs. Systems for recruiting new staff were carried out safely to ensure potential employees were suitable to work at the service.

People received their medicines when they needed them and in a safe manner.



Updated 14 September 2018

The service was effective.

Staff received a range of training that gave them the necessary skills and knowledge to carry out their roles and meet the specific needs of people using the service.

People were supported to have maximum choice and control over their lives and staff supported them in the least restrictive way possible.

People were provided with enough to eat to maintain a balanced diet.

People were supported to maintain good health and had access to appropriate services which ensured people received ongoing healthcare support.

Aveley Lodge was well maintained, bright and welcoming. The accommodation had been arranged to promote people�s wellbeing.



Updated 14 September 2018

The service was caring.

Staff were kind and caring and had developed good relationships

with people who used the service. People and their relatives were complimentary about the care provided.

People were supported to express their views and make decisions about their care. People were provided with the care support and equipment they needed to stay independent.

People's privacy, dignity and rights were respected and upheld.

People were supported to maintain important relationships.



Updated 14 September 2018

The service was responsive.

People's care plans had been developed from the initial assessment and covered all aspects of their care and how they preferred their needs met.

Staff responded quickly when people�s needs changed, which ensured their individual needs were met.

People had access to activities that were important to them. These were designed to meet people�s individual needs, hobbies and interests, which promoted their wellbeing. Staff were creative in finding ways to support people to live as full a life as possible.

Systems were in place to listen and respond to people�s concerns.



Updated 14 September 2018

The service was well led.

The registered manager had developed a strong and visible person

centred culture in the service. Staff were fully supportive of the aims and vision of the service.

Communication between staff and the management team was good. Staff felt supported and valued.

The management team were very passionate about the service they provided, led by example and inspired confidence in the staff team.

The management team and staff continually strived to improve the service and their own practice. The number of national awards won for best practice confirmed this.