Archived: Avens Court Nursing Home

Updated 3 March 2020

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 Care Act 2014.

Inspection team

The inspection was carried out by three inspectors.

Service and service type

Avens Court 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 did not have a manager registered with the Care Quality Commission. This meant that the provider was legally responsible for how the service is run and for the quality and safety of the care provided.

Notice of inspection

This inspection was unannounced.

What we did before the inspection

We reviewed information we had received from the service, such as statutory notifications of accidents and incidents and any safeguarding concerns. This included concerns raised by the emergency services, tissue viability nurse and the local authority. We used all of this information to plan our inspection.

During the inspection

We spoke with one person who used the service and two relatives about their experience of the care provided. We spoke with six members of staff.

We reviewed a range of records. This included three people’s care records and multiple medication records. A variety of records relating to the management of the service, including policies and procedures were reviewed.

After the inspection

We liaised with the local authority and the management service who had been engaged to take over oversight of the service.

Updated 3 March 2020

About the service

Avens Court Nursing Home is a care home providing personal and nursing care to 51 people aged 65 and over, many of whom may be living with dementia. The home, which is in a converted house and is set over two floors, each floor having its own lounge area. At the time of our inspection, there were 29 people living at Avens Court.

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

People were not safe living at Avens Court. There was a lack of staff to meet their needs and instances of potential abuse were ignored by staff or not raised as such. People had accidents and incidents and staff did not take steps to help ensure future accidents or incidents were reduced.

Although risks to people were identified, staff did not follow guidance to help keep people free from harm. People were left at risk of pressure sores, malnutrition and falling due to staff not having sufficient time to supervise people or taking the time to care for people in the way they needed.

People’s medicines were not handled safely. There were numerous gaps in medicines records which meant the registered provider could not guarantee people received the medicines they should have. People also lived in an environment which put them at risk of infection. There was a lack of effort by staff to regularly bathe people and people were left in wet bedding due to staff shortages and the inability to meet people’s needs in a timely manner.

The management and leadership of the service was ineffective. The registered provider had failed to act in a transparent and open manner and also failed to address previous concerns. Despite staff and relatives raising concerns, the registered provider had not listened and made changes to improve the care for people and the service they received. Although the registered provider had engaged a management service for Avens Court they demonstrated a lack of candour as they had not informed people, relatives or staff.

Despite audits being carried out at the service, shortfalls were not identified or addressed. Organisation of staff was inadequate in that there was a lack of senior management at the service. This left inexperienced staff, who did not know people, running the service.

The registered provider did not meet their requirements of registration in that there had been a lack of registered manager in the service for nine months. They had also failed to report potential safeguarding concerns to CQC.

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 (published 4 December 2019).

Why we inspected

Since our last inspection we received numerous concerns in relation to the management of the service, staffing levels, people’s needs not being met and a poor living environment in relation to cleanliness. As a result, we undertook a focused inspection to review the Key Questions of Safe and Well-led only.

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 Requires Improvement to Inadequate. This is based on the findings at this inspection.

We have found evidence that the provider needs to make improvements. Please see the Safe and Well-Led sections of this full report. We found continued breaches of regulation in Regulations 12, 17 and 18 of the Health and Social Care Act 2008.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Avens Court Nursing Home on our website at www.cqc.org.uk.

The overall rating for this service is ‘Inadequate’ and the service is 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 six 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.

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.