Avon Lodge

Avon Lodge is a residential care home providing personal care to older people and people living with dementia. At the time of the inspection there were 36 people living at Avon Lodge.

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

The service was safe and people were protected from harm. Staff were knowledgeable about safeguarding adults from abuse and knew what to do if they had any concerns and how to report them.

Risks to people using the service were assessed and their safety was monitored and managed, with minimal restrictions on their freedom.

People were supported by staff who had been checked to ensure they were safe to work at the service. There were sufficient numbers of suitable staff to meet people's needs and support them to stay safe.

Medicines were stored, managed, and administered safely. Staff were trained, and their competency checked.

People using the service were supported to have sufficient amounts to eat and drink and maintain a healthy balanced diet.

People were treated with kindness, respect, and compassion. People also received emotional support when needed. The atmosphere in the home was calm and relaxed. Staff knew people well and were knowledgeable about their needs and preferences.

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.

People and staff spoke highly of the management team and told us they felt supported. CQC's registration requirements were met and complied with, and effective quality assurance procedures were in place.

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 November 2021).

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.

At our last inspection we recommended the provider to review systems and processes around mealtimes to improve people’s experiences. At this inspection we found the provider had acted on our recommendation and they had made improvements.

Why we inspected

We carried out an unannounced inspection of this service in November 2021. Breaches of legal requirements were found. We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. 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 the last inspection to calculate the overall 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 Avon Lodge on our website at www.cqc.org.uk.

Follow up

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

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

People and relatives we spoke with said they felt Avon Lodge was a safe place to live and staff knew people well. Staff were described as kind and helpful by people and relatives.

We found concerns around how the service was managed and were not assured there was an effective management structure in place. There was a lack of consistent support for the registered manager. How staff were deployed during shifts was not effective and staff morale was low. Whilst people were given choice and control of their daily lives, the principles of the Mental Capacity Act (2005) were not met and some people were being unlawfully deprived of their liberty.

We have made a recommendation around ensuring people have a good mealtime experience.

People’s personal risks were assessed, and detailed guidance provided to staff to help minimise known risks. However, we found examples where people’s risks had not been adequately assessed. This meant people may not have been receiving appropriate care and support to meet their needs.

People received their medicines safely and there were systems in place to support this. Staff were recruited safely, and appropriate background checks completed prior to commencing employment. There were effective infection control procedures in place. Visiting was encouraged and visitors were informed of how to ensure people’s safety when visiting around COVID 19.

Staff received regular supervision and training to support them in their role. 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. Staff understood how to offer choice and support people in line with the MCA. However, we found the home did not always comply with the Mental Capacity Act (2005) and Deprivation of Liberty (DoLS) applications were not being made in a timely manner. People had choice around what they wanted to eat and drink.

There were regular staff meetings for staff and managers to share information. Feedback surveys were carried out to gain relatives feedback. Where people were able to, they were supported to give feedback on the care they received. The home worked with a lot of people who had advanced dementia and it was not always possible to gain their views. We observed these people’s experiences of their care during the inspection and saw staff knew people well and were able to tell if they needed anything, were happy or unhappy.

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 good (published 20 September 2018).

Why we inspected

This was a planned inspection based on the previous rating.

We reviewed the information we held about the service. No areas of concern were identified in the other key questions. We therefore did not inspect them. Ratings from previous comprehensive inspections for those key questions were used in calculating the overall rating at this inspection.

The overall rating for the service has changed from good to requires improvement. This is based on the findings at this inspection. We have found evidence that the provider needs to make improvement. Please see the safe, effective, and well-led sections of this full report.

We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.

We have identified breaches in relation to safeguarding service users from abuse and improper treatment, staffing and good governance.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will request an action plan for 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 return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The home provides personal care and support for up to 36 people, some of whom have dementia. At the time of the inspection there were 31 people living at Avon Lodge. It is a large two storey building and people’s bedrooms are on both first and second floors. There is a large communal lounge / dining room as well as a smaller communal lounge. The home has a large well-kept garden with outdoor seating areas.

There was a manager in place who had applied to CQC to become the 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.

The home had been rated as ‘inadequate’ in September 2015 and again in April 2016. At an inspection in October 2016 we rated the service ‘requires improvement’ overall but ‘inadequate’ in well-led’. At our last inspection on 21 and 22 March 2017 we found that there had been significant improvements and found no breaches of regulations. However, we needed to be assured that improvements would be embedded and sustained and the home was again rated as ‘requires improvement’.

At this inspection we found that the improvements had been embedded, further improvements had been made and there were no breaches of regulation. The home is now rated ‘good’.

People told us that they felt safe living at Avon Lodge. Staff had received safeguarding training and understood how to recognise and report abuse.

We observed warm and friendly interactions between staff and people throughout the inspection. Staff knew people well.

People’s risks were well documented and care was provided to people in the least restrictive way whilst being aware of people’s personal risks. Risks were regularly reviewed.

The home assessed and monitored people’s risk of malnutrition and pressure ulcers and made referrals to specialist health professionals when necessary. Fluid charts were not always completed properly. However, this was addressed at the time of the inspection.

Medicines were well managed and people received their medicines safely and on time. People received ‘as needed’ medicines when necessary. However, there were no protocols for when to administer these medicines. Following the inspection, the registered manager addressed this issue.

Staff were aware of infection control and how to keep people safe from the spread of infection. The home provided gloves and aprons for staff when delivering personal care.

There were regular maintenance checks and staff were aware of how to report maintenance issues.

The home was clean and smelled fresh throughout the inspection.

Staff received regular supervision, appraisal and training to support them in their role.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service support this practice.

There were individualised care plans written from the point of view of the people that were supported. Care plans were detailed and provided enough information for staff to support people. Care plans were regularly reviewed and updated immediately if changes occurred.

The home recognised that stimulation and enjoyment were essential to people’s wellbeing. There was a wide variety of activities that people could choose to take part in. People were supported and encouraged to engage in activities.

People received good quality food and there were always drinks available to ensure hydration. Where people required specialist diets, we saw that this was being provided.

People and relatives were encouraged to help plan end of life care in a tailored way. Staff were compassionate regarding caring for people at the end of their lives.

There was a complaints process in place and people and relatives knew how to make a complaint. Complaints were investigated and followed up.

Visitors told us that they felt welcome within the home and able to visit whenever they wanted.

Audits were carried out across the service on a regular basis on medicines management, health and safety and the quality of care. Surveys were completed with people who use the service and their relatives. Where issues or concerns were identified, the manager used this as an opportunity for change to improve care for people.

People and relatives felt that there had been a great improvement in the service. The manager and management team were accessible to people and relatives were confident in the care that was being provided.

At our last inspection on 25 and 26 October 2016 we found that Avon Lodge had continued to fail in improving standards of care to a level that met the regulatory requirements. We found significant on-going shortfalls in the care provided to people and identified breaches of regulations 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. This related to risk assessments, staff not receiving regular supervision or appraisal to monitor performance and overall good governance of the service. However, the service had improved and was rated requires improvement overall. Well-led remained rated as inadequate and the service was kept in special measures. At this inspection we found that the provider had addressed these breaches and was now meeting the regulatory standards.

Avon Lodge is a residential care home that provides personal care and support for 36 people, some of whom have dementia. However, following our inspection and findings in September 2015, the local authority placed an embargo on Avon Lodge accepting any new referrals. This meant that the service was not allowed to admit any new residents. At the time of this inspection, there were 21 people using the service.

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 was present during the inspection.

People and relatives were positive about the home and told us that they and their relatives felt they were safe and well cared for.

There were enough staff to ensure that people were provided with care that met their needs. The service assessed staffing levels using a dependency level assessment tool. Staff did not appear rushed and spent time talking with people. There was a homely atmosphere at the service.

The service had introduced new risk assessments. Risk assessments were tailored to the individual and gave staff detailed guidance to ensure that risks were mitigated against in the least restrictive way.

Staff had received training on medicines administration and people were supported to take their medicines safely. Medicines were accurately recorded on medicine administration (MAR) sheets. There were staff on duty every night that were assessed as competent to administer medicines.

Falls were actively monitored. There were monthly falls audits and analysis and people were referred to a local falls clinic where appropriate. Accidents and incidents were documented and followed up.

Procedures relating to safeguarding people from harm were in place and staff understood what to do and who to report to if people were at risk of harm. Staff had an understanding of the systems in place to protect people who could not make decisions and were aware of the legal requirements outlined in the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS).

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. The policies and systems in the service supported this practice.

Staff received regular, effective supervision and attended regular team meetings. All staff had received an annual appraisal which reviewed their work and training needs.

People were given a choice of foods each day and menu options were clearly displayed in the home. People that required specialist diets were catered for and the chef and staff were aware of people’s dietary needs.

People had access to regular healthcare appointments and referrals were made when necessary. Relatives were positive about the healthcare referrals and care that people received.

People were able to get up and go to bed when they wished. Waking and sleeping preferences had been recorded in people’s care plans and staff were aware of those preferences.

End of life wishes had been documented in collaboration with relatives and, where appropriate, healthcare professionals.

People and relatives said that they were treated with dignity and respect. Staff were able to give examples of how they ensured that they promoted dignity and respect when caring for people.

New care plans had been implemented which were individualised and were written from the point of view of the people that were supported. Care plans were detailed, person centred and provided enough information for staff to support people.

The service was providing activities every weekday from 10:00 until 17:00. People were engaged and encouraged to participate. We observed staff encouraging people to engage in the activities. The service has planned to extend the activities programme to seven days a week.

Audits were being completed for various aspects of these service which included action plans and records of how the identified issues had been addressed.

The management structure was more stable and staff were aware of managers roles and responsibilities.

Staff had regular team meetings where they were able raise any concerns. Management also used tis as an opportunity to share information.

Services that have been given a rating following an inspection are legally obliged to display their rating on their website, if they have one, and at the registered location where care is provided. The service was displaying its rating provided by the Care Quality Commission at the last inspection in clear view by the front door of the home.

This service has been in Special Measures. Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. During this inspection the service demonstrated to us that improvements have been made and is no longer rated as inadequate overall or in any of the key questions. Therefore, this service is now out of Special Measures.

Whilst improvements have been made we could not improve the rating for safe or rate well-led as more than Requires Improvement as it needs to be demonstrated over time that these improvements have been embedded.

This inspection took place to check if the provider had made the required improvements to ensure that they were meeting the legal requirements. This inspection took place over two days on 25 and 26 October 2016 and was unannounced. At our last inspection on 14 and 15 April 2016, we found that the provider was not meeting all the standards that we inspected. We identified breaches of regulations 9, 11, 12, 14, 16 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Care and treatment for people was not being provided safely. Risk assessments to identify and mitigate significant risks to people were not in place. Care plans failed to reflect people’s preferences regarding care and treatment provided. The home did not provide activities for people to encourage communication and stimulation. There was a significant level of poor care and risks to people that used the service that were not identified or acted upon.

Avon Lodge is a residential care home that provides personal care and support for 36 people, some of whom have dementia. However, following our inspection and findings in the September 2015 inspection, the local authority placed an embargo on Avon Lodge accepting any new referrals. This means that the service was not allowed to admit any new residents. At the time of the inspection, there were 24 people using the service.

The home did not have a registered manager. However, a manager had been appointed in April 2016 and was in the process of applying for registered manager status with the Care Quality Commission (CQC). 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.

Risk assessments had not been completed on subjects such as high-risk medicines or serious chronic health conditions. Diagnosis of two chronic health conditions had been included in care plans but no risks associated with these conditions had been identified. However, other risks were well documented and provided staff with guidance on how to mitigate the risks.

Staff were not receiving regular supervision. Staff had not received an annual appraisal.

The management structure of the home was confusing and the management team were unaware of what each other’s roles were. There was poor communication between the management team.

One person had not received their prescribed medicines following a healthcare assessment for 21 days. This had not been identified by the service.

The service completed audits. However, there were no action plans or documentation of the outcome of these audits. The service was not ensuring that audits improved the standards of care for people using the service.

At our last inspection Mental Capacity Act (2005) assessments had not been completed for any people living at the home and in any area of decision making. At this inspection, we found that MCA assessments had been completed. However, the service had completed the same seven assessments for all people. MCA assessments completed by the home were not decision specific and contradicted healthcare professional’s assessments.

Staff had an understanding of the systems in place to protect people who could not make decisions and were aware of the legal requirements outlined in the Mental Capacity Act (MCA) 2005 and the Deprivation of Liberty Safeguards (DoLS). The home had applied for Deprivation of Liberty Safeguards (DoLS) for people where appropriate. Where DoLS had been authorised, there were review dates in place.

At our last inspection there had been no activities provided for people. In the past six months the home had begun to provide entertainment and activities for people. There had been day trips to the seaside and the zoo. However, activities were not tailored to individuals. People’s interests and preferences were not taken into consideration when booking activities.

Guidance for people with swallowing difficulties was now being followed. There were reviews of people’s swallowing difficulties with a Speech and Language Therapist (SALT).

People had healthcare appointments that met their needs. Staff were aware of how to refer people to healthcare professionals when necessary. There were records of appointments and reviews in people's files.

At our last inspection, care plans were not person centred and did not state people likes and dislikes. Where people were unable to have input into planning their care, there were no records of best interests meetings or decisions. At this inspection, the provider had completed new care plans for all people using the service. These were person centred and documented that people were involved in planning their care. Where they were unable to be involved, there were records of best interests meetings.

There was a complaints procedure in place which people and relatives had access to.

Procedures relating to safeguarding people from harm were in place and staff understood what to do and who to report to if people were at risk of harm.

The service provides care and support to people living with dementia. At our last inspection, we found that staff had not received training on working with people living with dementia or behaviour that challenged. During this inspection, records confirmed that half of the staff had received training in dementia care and working with behaviour that challenges.

We observed caring interactions between staff and people. Staff knew people well and were able to tell us about individuals likes and dislikes.

People were consulted on the food provided. Daily menus plans were in place that showed a good choice of food available, including vegetarian and halal options. People on specialist diets such as puree and fork mashable were provided with food that was at an appropriate consistency and well-presented.

The provider had redecorated areas of the home and a programme of works was in place. A new treatment room was available where people could see healthcare professionals in private.

Avon Lodge has continued to fail to improve standards of care to a level that meets the regulatory requirement. We found significant on-going shortfalls in the care provided to people. We identified breaches of regulations 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

Following that inspection the service was placed into special measures and conditions were placed upon the provider’s registration.

Special measures means that the Care Quality Commission keeps the service under review and it is re-inspected within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. At this inspection we found that the provider had failed to improve standards and quality of care over the past six months to an acceptable standard. There were on-going breaches of Regulations 9, 11, 12, 16 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We also identified a breach under Regulation 14 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Avon Lodge is a residential care home that provides personal care and support for 36 people, some of who have dementia. However, following our last inspection and findings, the local authority placed an embargo on Avon Lodge accepting any new referrals. This means that the service was not allowed to admit any new residents. At the time of the inspection there were 27 people using the service.

The home did not have a registered manager. However, a manager had recently been appointed and was in the process of applying for registered manager status with the Care Quality Commission (CQC). The manager had been in post for three weeks.

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.

Despite new care plan templates, care plans still did not contain enough information to provide personalised, high quality care. People, where they were able, were still not involved in planning their care. Where people were unable to have input into planning their care, there were no records of best interests meetings or decisions. This meant that people's views and opinions were not taken into account.

Risk assessments were not detailed and did not provide staff with guidance on how to mitigate risks that had been identified. Risk assessments had not been completed on subjects such as, high risk medicines or behaviour that challenges. Some risk assessments had not been completed appropriately and important information had been left out. This put people at risk of harm.

Guidance for people with swallowing difficulties was not always being followed. There was no review of some people’s swallowing difficulties with a Speech and Language Therapist (SALT).

There were still few meaningful activities in place within the home. An activities coordinator had been appointed. However, there were no activity plans in place. People still did not leave the home and there were no external activities organised. However, following the inspection we were told by relatives and staff that day trips and activities had started to happen.

There was no evidence that complaints were responded to. There was no evidence of learning or changing practice to improve care and communication.

There were no Mental Capacity Act (2005) assessments for any people living at the home, in any area of decision making. We looked at ten people's care files. There was no evidence of best interests meetings or plans. The home's training records showed that staff had received training on the MCA in the past six months. Only two staff were able to explain what the MCA was and how it could impact on the lives of the people that they supported.

The home had applied for Deprivation of Liberty Safeguards (DoLS) for people where appropriate. Where DoLS had been authorised, there were review dates in place. Staff were unable to explain what DoLS was or how it impacted on people.

The service provides care and support to people living with dementia. Staff had not received training on working with people living with dementia or behaviour that challenged.

Procedures relating to safeguarding people from harm were in place and staff understood what to do and who to report it to if people were at risk of harm.

Overall, we observed caring interactions between staff and people. Staff knew people well and were able to tell us about individuals likes and dislikes.

Staff had been trained in manual handling in the past six months. Manual handling practices were appropriate and staff communicated well with people during these procedures.

People were consulted on the food provided. Daily menus plans were in place that showed a good choice of food available, including vegetarian and halal options.

The provider was redecorating the home and a programme of works was in place. A new treatment room and disabled access shower room had been created.

Avon Lodge has failed to improve standards of care to a level that meets the regulatory requirement. We found significant on-going shortfalls in the care provided to people. We identified breaches of regulations 9, 11, 12, 14, 16 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Full information about CQC’s regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.

At this inspection we saw that staff were mostly appropriately supported by the provider to deliver care and treatment to people safely and to an appropriate standard. Records showed and the manager and staff told us that staff supervisions and appraisals had mostly been completed. Staff had received additional training and refresher training. Appraisals, supervisions and further refresher and additional training were scheduled for 2014 in accordance with the provider's policy.

We received concerns during and after our visit regarding the number of staff deployed at the service. The provider had reviewed the number of staff required and was taking steps to respond to those needs.

We saw that people's needs were assessed and care was planned and delivered in line with their individual care plan. The registered manager and staff were praised by relatives. One relative told us "the staff and manager are really nice".

Records showed that prior to people living at the home the provider had made an assessment of people's needs. People were regularly visited by healthcare professionals including GPs, District Nurses and Opticians. This meant that people were able to obtain health and social care support.

Maintenance of the premises was conducted as and when the need arose. There was planned maintenance of the gas, water and electricity systems and fire alarms.

We saw records and were told by the manager and staff that some staff had received training and had supervision sessions but had not received annual appraisals.

People who use the service and their representatives were asked for their views about their care and treatment by the service. Records showed that monthly audits had been made by the area manager.