Avalon West Yorkshire Services

Updated 1 October 2022

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 carried out by two inspectors 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

This service is a domiciliary care agency. It provides personal care to people living in their own houses and flats.

This service provides care and support to people living in two ‘supported living’ settings, so that they can live as independently as possible. People’s care and housing are provided under separate contractual agreements. CQC does not regulate premises used for supported living; this inspection looked at people’s personal care and support.

Registered Manager

This service is required to have a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. This means they and the provider are legally responsible for how the service is run and for the quality and safety of the care provided.

At the time of our inspection there was a registered manager in post.

Notice of inspection

We gave the service 24 hours’ notice of the inspection. This was because we needed to be sure the registered manager would be in the office to support the inspection.

Inspection activity started on 9 August 2022 and ended on 14 September 2022. We visited the location’s office on 9 August 2022. We visited the supported living services on 22 August 2022 and 2 September 2022.

What we did before the inspection

We reviewed all the information we had received about this service since its registration with us in 2020. We requested feedback from stakeholders, including the local safeguarding and commissioning teams. We used the information the provider sent us in the provider information return. 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 used all this information to plan our inspection.

During the inspection

We spoke with seven people who used the service and five relatives about their experience of the care provided. We gathered information from 11 staff members including the registered manager, regional operations director, service managers and care staff.

We reviewed a range of records including; six peoples care plans, risk assessments and medicines records. We looked at five staff files in relation to recruitment. We reviewed a variety of records relating to the management of the service, including policies, procedures and quality assurance records. Following the site visits, we reviewed further information and evidence from the provider. This included information relating to medicines, governance, mental capacity assessments and care plans.

Updated 1 October 2022

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.

About the service

Avalon West Yorkshire Services is a domiciliary care agency and a supported living service which provides personal care to people in their own homes and individual flats. Support is provided to people with a learning disability and autism, mental health conditions and physical disabilities.

The supported living service includes two buildings with individual flats. One building has an accessible communal area, an office and a sleep room for staff. At the time of our inspection there were 41 people using the service. Twenty-five people were receiving a regulated activity.

Not everyone who used the service received personal care. CQC only inspects where people receive personal care. This is help with tasks related to personal hygiene and eating. Where they do, we also consider any wider social care provided.

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

Right Support

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. Most staff we spoke with demonstrated a good understanding of the mental capacity act (MCA); however, some staffs language when referring to MCA and consent was not in line with best practice. People's support needs and risks were assessed to identify how their care could be provided safely. Staff supported people to achieve their goals, take part in meaningful activities and pursue their interests. The provider was struggling with recruitment and the management team were filling gaps in staffing to meet people’s needs. We discussed this with the leadership team who evidenced steps taken to promote recruitment and retention of staff through regularly advertising, financial incentives and a local recruitment drive.

We have made a recommendation the provider monitors and refreshes staffs understanding of MCA and consent.

Right Care

People received kind and compassionate care. Staff protected and respected people's privacy and dignity. Staff understood and responded to people’s individual needs. People had access to health care professionals when they needed them. The provider was developing care plans to reflect people’s choices, preferences and wishes should they need support at the end of their life. Medicines were managed safely. Not all staff were compliant with training courses. However, the provider had an action plan in place to achieve higher levels of compliance.

We have made a recommendation the provider continues to promote full compliance with training.

Right Culture

People received good quality care, support and treatment because staff knew their needs well and they received regular supervision from managers. Feedback from people and relatives was mostly positive. Relatives felt support and care had been provided to a high standard with very good outcomes for people. Decreased staffing levels was having an impact on staff morale, this was reported by both staff and relatives. Tasks related to the governance of the service had also naturally been impacted due to the management team supporting people in addition to their responsibilities. However, the provider through the commitment of the management team and staff, had minimised the impact on people’s care and support.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

This service was registered with us on 30 December 2020 at their current address. The last rating for the service at the previous premises was Good, published on 17 March 2020.

Why we inspected

This inspection was prompted by a review of the information we held about this service.

Follow up

We will continue to monitor information we receive about the service, which will help inform when we next inspect.