Acorn Meadow

Avandale Lodge is a residential care home providing personal care to 17 people at the time of the inspection.

The service had dedicated staff to ensure people were received safely and continued to be supported in the service in accordance with national guidance.

They supported people and their relatives to understand the policies and procedures surrounding protection against COVID 19, the isolation processes and how the service could help them to keep people safe.

During our visit we observed the staff using Personal Protective Equipment, (PPE) safely. The registered manager told us sufficient stocks of PPE were available and we confirmed this on the visit. A staff member said, “We have always had plenty of PPE.”

People living in the home and staff were tested regularly for COVID-19. There were no staff employed who had not been vaccinated as now required.

The home was clean and hygienic. Cleaning schedules were in place and PPE stations placed around the home. Additional cleaning protocols were in place to ensure all areas of the building were regularly sanitised.

Relatives spoke very positively about visiting and the communication from the service. Comments included; "Good communication and I have been kept informed of any changes", "Staff keep in regular touch to let me know how [Name] is" and "The process for visiting is really clear and is followed every time. [Name] and other residents come first, their safety is paramount."

We found the following examples of good practice.

The environment was clean and hygienic with an appropriate cleaning schedule in place to minimise the spread of infection. Staff wore appropriate personal protective equipment (PPE) and had their competency to use this assessed on a regular basis.

Any visiting professionals to the service have checks on their temperature and are required to complete a questionnaire in line with current COVID-19 guidelines.

COVID-19 care plans had been devised by the service for individuals to take the risk of them being infected into account. All people who use the service are regularly tested and have their temperatures daily twice daily. Staff are also subject to COVID-19 testing.

Despite restrictions; people who used the service appeared relaxed, comfortable and a home-like atmosphere was sustained..

Further information is in the detailed findings below.

Avandale Lodge is a residential care home providing personal care to 12 people at the time of the inspection. The service can support up to 48 people.

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

After the last inspection, the provider removed the provision of nursing care and a significant number of people were moved to alternative accommodation. This decision was made, in part, due to difficulties the provider had experienced in recruiting and maintaining a consistent nursing team for the home which was impacting on the quality of the service being provided.

Recording of accidents and incidents and reporting of potential safeguarding concerns had improved. Systems were in place to ensure the safety and wellbeing of people. Care plans and risk assessments were regularly reviewed, people received their medicines safely and people could share their views on the service being provided at Avandale Lodge.

The provider had ensured that they had followed the principles of the Mental Capacity Act 2005 to assess people’s ability to consent to decisions about their care. 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 were offered choices and involved in decision making relating their care.

People’s care plans contained detailed person-centred information about them to ensure staff could meet their needs and preferences. Activities to occupy and interest people within the home had improved and the communication needs of people were known which ensured information could be presented to people in the most appropriate format.

Since our last inspection, a new registered manager was appointed to work in the home. Staff and relatives spoke positively of the new registered manager. We also received positive feedback from the local authority about improvements that had been made in recent months.

Some improvements had been made to ensure the environment was appropriate for people living with dementia and further refurbishment plans were in place.

Staff were motivated to deliver a high standard of care. They were well trained and told us they felt more positive and supported in their role.

People had access to healthcare and the registered manager worked closely with other agencies to ensure successful outcomes were achieved.

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 02 January 2019) and there were multiple breaches of regulation including safeguarding people from the risk of abuse, ensuring people consented to care, providing person centred care and good governance. 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.

Why we inspected

This was a planned inspection based on the previous rating.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

The service had a registered manager who was registered with us in January 2018. 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 manager was present during the days of our visit.

Avandale 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. Avandale Lodge is registered to accommodate 48 people living with dementia. At the time of our visit, 39 people were living there.

During the last inspection on 7th, 9th and 12th March 2018 we found that there were a number of improvements needed in relation to safe care and treatment, staffing and good governance. These were breaches of Regulations 12, 13, 17 and18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The service was rated as requires improvement overall and inadequate in the Safe domain.

Following the last inspection, we asked the provider to complete an action plan to show what they would do and by when to improve the key questions Safe, Effective, Caring, Responsive and Well Led to at least good. The provider sent us an action plan that specified how would they would meet the requirements of the identified breaches.

During this inspection we found that whilst some of the required improvements had been made, other required improvements had not been met and that other areas of improvement had been identified.

Improvements had been made to the management and administration of medicines. We found that medicines were managed safely in accordance with good practice guidelines. Staff had received training and had their competency assessed.

Improvements had been made with regards to the submission of notifications to the CQC where specific incidents had occurred that adversely affected the wellbeing of people. This is a legal duty which the provider is required to meet.

Some improvements had been made to ensure that agency staff had more information about the needs of people who used the service. This ensured that agency staff were better placed to meet the needs of people.

This visit found that some improvements had not been made and as a result breaches had been repeated. These related to care and treatment with the registered manager not reporting low level safeguarding concerns to the local authority, not taking steps to investigate events where people who used the service sustained unexplained injuries and not using the registered provider’s systems fully to report incidents that had occurred. Another related to the governance of the service whereby shortcomings in the quality of the service had not been identified during audit undertaken. Further shortcomings were identified in respect of managerial support for staff when the registered manager had been absent.

The use of agency staff had decreased but all registered nurses on nights were still sourced by an agency.

We have raised a recommendation in respect of the premises being supportive for those who live with dementia.

Despite shortcomings in the following of local authority procedures, staff were aware of the types of abuse that could occur and were familiar with the reporting procedure.

Staff recruitment was robust and included appropriate checks on new members of staff.

The premises were clean and hygienic. Assessments were in place to minimise the spread of infection.

Risk assessments relating to malnutrition and the development of pressure ulcers were now completed and more effective.

Equipment used was subject to regular checks to ensure that people were safe.

Staff received the training and supervision they needed to perform their role.

New staff received a structured induction as an introduction to their roles and responsibilities.

The nutritional needs of people were met. Links were in place to health professionals to ensure that the health needs of people were met.

Sensitive information was kept secure at all times. As a result people could be confident that their personal details were appropriately and safely secured.

When staff interacted with people, these were conducted in a kind and respectful manner. People’s privacy was upheld.

People were encouraged to be as independent as possible.

A robust complaints procedure was in place. Arrangements were in place outlining the wishes of people when they reached the end of their lives.

Staff told us that the registered manager was supportive and approachable to them. Relatives told us that the registered manager maintained a presence within Avandale Lodge and was available to deal with their queries.

The views of people were gained by the registered provider. The rating following the previous inspection was on display.

The last inspection of the service was carried out on 6 & 7 July 2017 and published on 22 August 2017. At that time the service was rated as good.

Avandale Lodge Nursing Home 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.

Avandale Lodge Nursing Home is purpose built and provides care for up to 48 people who require support with nursing and personal care. The service specialises in supporting older people and at the time of the inspection there were 44 people living at the service. Bedrooms are accommodated on the ground and first floor and are all single occupancy with en-suite facilities. There is a lounge, dining room and accessible bathroom facilities on both floors.

There was a registered manager in place. 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 provider had a range of checks in place to monitor the quality and safety of the service such as medication administration records, accident and incident records and people's care plans and monitoring records however these had not always been effective at identifying areas that needed improvement.

The provider had not ensured there was always sufficient numbers of relevantly qualified and experienced staff that had a good understanding of people's needs on duty. The service was heavily reliant on agency staff some of whom had not received an induction to the service. There had been no permanent nurses on duty at night during February 2018 and one night every week there had only been one permanent care assistant on duty.

The administration of medicines was not always safe. The provider could not be assured sufficient time had always been left between the administration of people’s morning and lunch time medicines. The guidelines for when ‘as and when needed’ medicines could be administered to people were not clear. This increased the risk of people not receiving their medicines as they needed them.

Risks to people were not always managed safely. Most people did not have a call bell to use when they needed assistance and sensor mats were not always positioned so they would be activated if the person moved. Risks of people becoming malnourished, developing pressure ulcers and experiencing falls had been assessed but were not always up to date and did not always reflect people’s current needs. This increased the risk of people not receiving care that met their needs.

The mood and behaviour of people with a history of being aggressive to others was not always being monitored. Therefore staff could not identify patterns in behaviour and take action to reduce the risk of incidents occurring. Although pressure relieving equipment was in place for people who had developed pressure sores, repositioning charts showed people were not always being repositioned on a regular basis.

The provider had not ensured that appropriate action to safeguard the people from abuse had always been taken. Incidents of people being verbally and physically aggressive towards others and incidents of poor staff practice had been reported to the registered manager and action taken to protect people from harm. However these incidents had not been always been referred to the local authority for them to consider under local safeguarding procedures or reported to CQC as required.

The registered manager and staff had received training in the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS), and people were being supported to make decisions in their best interests. However records had not always been completed appropriately.

Each person’s needs had been assessed before they moved into the service and a care plan had been developed in consultation with them and their relatives. However these were not always up to date so the provider could not be assured they always accurately reflected people’s needs, wishes and preferences.

People were treated with dignity and respect most of the time but people were not always supported by staff who knew them well and had a good understanding of their personalities and personal preferences.

People had the opportunity to participate in group activities that they enjoyed and staff spent time with people in their rooms on a one to one basis. However improvements were needed to increase the range of activities on offer and ensure people were not socially isolated.

People were supported to access to a range of healthcare professionals and their wishes on their end of life care had been discussed with them and documented. People had a choice of nutritious food and drink at meal times and specialist diets were catered for.

The design and adaptation of the building met most people's needs but signage accessible to people living with dementia needed to improve.

A system was in place to ensure people knew how to complain and people were asked for their opinion of the service by way of a satisfaction survey and at resident and relative meetings.

The recruitment of new staff was safe and all staff had received an induction to the service before working unsupervised. Staff felt supported and received the training they needed to undertake their role and support people effectively.

Equipment and premises were safe. There was a plan in place for the safe evacuation of the premises in case of emergency. The environment was clean and hygienic. Staff had access to and used personal protective equipment (PPE) such as gloves and aprons. There were processes in place for the recording of accidents and incidents and these were monitored.

The management team were open and transparent during our inspection and worked with us proactively. During the inspection immediate action was taken to compile and implement an action plan to address the concerns we had highlighted at this inspection.

You can see what action we told the provider to take at the back of the full version of the report.

Avandale Lodge is registered to provide nursing care and accommodation for up to 48 people. The service is spread over two floors and supports people living with Dementia, mental and physical health needs. At the time of the inspection there were 44 people living at the service.

The service did not have a registered manager in post. The manager in post had previously been registered with the CQC before giving up their registration in June 2017. 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.

In April 2017 there had been an outbreak of influenza within the service which had increased people’s dependency levels. This had also impacted upon staffing levels and the management of the service. The registered provider had not effectively implemented contingency measures to manage this situation. Because of this we have made a recommendation relating to the contingency measures employed by the registered manager in relation to events such as these.

People received their medication as prescribed. We reviewed a sample of people’s medication and found that the correct quantities were being stored. Protocols were in place for administering PRN (‘as required’) medication so that staff knew when to administer this. Where issues had arisen with people’s medication the manager had been proactive in following this up to address this directly with staff.

People were protected from the risk of abuse. Staff had completed training in safeguarding vulnerable adults and knew how to report any concerns they may have. There was a whistleblowing procedure In place which would enable staff to raise their concerns anonymously either inside or outside the organisation.

There were sufficient numbers of staff in post to meet people’s needs. Staff were able to respond to call bells in a timely manner, and during one incident they responded quickly and effectively to maintain one person’s wellbeing.

Recruitment processes were robust and helped protect people from the risk of abuse. Appropriate checks had been completed by the registered provider prior to a member of staff being employed to ensure they were of suitable character.

Staff had received the training the needed to carry out their role effectively. They had completed training in areas such as moving and handling, infection control and the Mental Capacity Act 2005 (MCA). There was also an induction process in place for new staff which prepared them for their role, and enabled the manager to monitor their performance to assess their suitability for the 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 place within the service supported this practice.

Staff treated people with dignity and respect. People commented positively on staff and we observed examples of good interactions. People presented as being at ease and relaxed in the presence of staff.

People’s confidentiality was protected. Records containing personal information was stored securely in locked offices, which remained secure when not in use.

Care records were personalised and contained important information about the care and support that people required. These were reviewed on a monthly basis or where any developments occurred which meant these needed to be updated. This ensured that staff had access to accurate and up-to-date information.

There were quality monitoring processes in place to monitor the standard of care being provided to people. Information gathered as part of these quality monitoring processes was analysed and appropriate action had been taken to make improvements where necessary.

'It's the best place I've been. They're all great.'

'That's a friend ' she's a very nice girl' (about a member of staff)

'She's a good working sister. She says she loves me' (about a nursing member of staff)

The relatives we spoke to were happy with the care and support provided. They were very positive about the staff and the way in which they provided support.

We spoke to three staff who said that a good service was provided and that people were well looked after.

We observed positive interactions between the people who used the service and the staff. Staff were attentive, had a caring attitude and were supportive.

We found that there were practices in place to ensure that the people who used the service were respected and that they were involved in the delivery of the service they received as far as this was possible.

Records showed that people had been assessed before they began to use the service and they had a care plan in place detailing the support they needed and how staff were to minimise risks to their well-being.

The staff were provided with the support they needed to enable them to meet the needs of people with dementia.

We found that the service involved and communicated with health and social care professionals when they were needed to ensure the needs of the people who used the service where appropriately met.

There were systems in place to monitor the quality of the service for people who had dementia.

We observed positive interactions between the people who used the service and the staff. Staff were attentive, had a caring attitude and were supportive.

We spoke to one health professional who supported people who used the service. They said that a good service was provided at the home.

There were practices in place to ensure that the people who used the service were respected and that they were involved in the delivery of the service they received as far as this was possible.

Records showed that people had been assessed before they began to use the service and they had a care plan in place detailing the support they needed and how staff were to minimise risks to their well-being.

The staff were provided with the support they needed to enable them to meet the needs of the people who used the service.

There were systems in place to monitor the quality of the service.

LINKs* had made a recent visit to the home. Their report gave a positive description of the services provided. They made some recommendations for improvements to which the manager has responded.

** LINKs are networks of individuals and organisations that have an interest in improving health and social care services. They are independent of the council, NHS and other service providers.